Postsurgical cognitive side effects can have major implications for the level of care, length of hospital stay, and the patient’s perceived quality of care, especially in elderly and fragile patients. A nationwide survey of Swedish anaesthesiologists and nurse anaesthetists has found there is low awareness of the risks of cognitive side effects following surgery. Furthermore, only around half of the respondents used depth-of-anaesthesia monitors.

Patients generally expect to make a rapid recovery from anaesthesia with a minimum of side effects. The main focus by anaesthesia personnel centres around how to minimize cardiovascular and pulmonary risks and on the management of postoperative pain, nausea, and vomiting. According to the survey results, less attention is being paid to cognitive side effects following surgery, yet these complications can have major implications for the patient.

‘We found that Swedish anaesthesia personnel viewed risk assessment, prevention, and handling of postoperative delirium and postoperative cognitive dysfunction of rather low importance. Protocol and/or standardized routines were only rarely implemented,’ observes senior investigator Professor Jan G. Jakobsson, MD, PhD, of the Department of Anesthesia & Intensive Care, Institute for Physical Science, Karolinska Institute, Stockholm, Sweden.

Postoperative cognitive impairments may arise early on after surgery, such as the short-lasting, but still distressful postoperative emergence agitation (EA). Postoperative delirium (POD) usually makes its debut one or two days after surgery, sometimes giving rise to major concerns. The more subtle but longer lasting postoperative cognitive dysfunction (POCD) generally starts during the first week after surgery, but may last for a month. Although these side effects are of major concern for both hospitals and patients, they have received less attention from anaesthesia personnel.

To gain insight regarding routines and practice for risk assessment, diagnosis, and management of postoperative cognitive side effects, and the use of EEG-based depth-of-anaesthesia monitoring (DOA), investigators sent a web-based validated questionnaire to over 2,500 Swedish anaesthesiologists and nurse anaesthetists. The questionnaire consisted of three sections covering subjective preferences, routines, and practices related to the perioperative handling of EA, POD, POCD, and awareness. The response rate was 52%.

In general the respondents considered the risk for neurocognitive side effects to be the least important during the preoperative assessment, while the risk of awareness with recall (when patients are able to recall the surgery) as well as traditional cardiac and pulmonary risk was considered of high importance.

It has been suggested that the use of EEG-based DOA monitoring to fine-tune and tailor anaesthetic delivery can reduce the risk of postoperative cognitive side effects. Previous surveys of anaesthetic practice in Sweden showed a high degree of standardization and that structured protocols for the perioperative management are in place. However, the results of this survey were more diverse. EEG-based DOA monitors were used in half of all departments, but the frequency and indication for their use varied.

‘Respondents were overall quite skeptical about the value of EEG-based DOA monitors, however their use in patients at risk for awareness was more positive among the nurse anaesthetists than the anaesthesiologists,’ notes Professor Jakobsson. ‘This attitude to DOA monitoring may be due to the rather negative stance of the Swedish Council on Health Technology Assessment regarding these devices. This is in contrast to the national guidelines in the UK, which support the use of DOA monitoring in at-risk patients.’

‘The results show there is a need to improve the knowledge of anaesthesia personnel about risk factors, prevention and management of postoperative cognitive side effects,’ concludes Professor Jakobsson. EurekAlert

Poor oral health and hygiene are increasingly recognized as major risk factors for pneumonia among the elderly. To identify modifiable oral health-related risk factors, lead researcher Toshimitsu Iinuma, Nihon University School of Dentistry, Japan, and a team of researchers prospectively investigated associations between a constellation of oral health behaviours and incidences of pneumonia in the community-living of elders 85 years of age or older.

At baseline, 524 randomly selected seniors (228 males, 296 females, average age was 87.8 years old) were examined for oral health status and oral hygiene behaviors as well as medical assessment, including blood chemistry analysis, and followed up annually until first hospitalization for or death from pneumonia. Over a three-year follow-up period, 48 events associated with pneumonia were identified (20 deaths and 28 acute hospitalizations). Among 453 denture wearers, 186 (40.8%) who wore their dentures during sleep, were at higher risk for pneumonia than those who removed their dentures at night.

In a multivariate Cox model, both perceived swallowing difficulties and overnight denture wearing were independently associated with approximately 2.3-fold higher risk of the incidence of pneumonia, which was comparable with the high risk attributable to cognitive impairment, history of stroke and respiratory disease. In addition, those who wore dentures while sleeping were more likely to have tongue and denture plaque, gum inflammation, positive culture for Candida albicans, and higher levels of circulating interleukin-6 as compared to their counterparts.

This study provides empirical evidence that denture wearing during sleep is associated not only with oral inflammatory and microbial burden but also with incident pneumonia, suggesting potential implications of oral hygiene programs for pneumonia prevention in the community. The International Association for Dental Research (IADR)

The publication of the new joint ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management introduces a number of recommendations in the field. Among other topics, the Guidelines include updated information on the use of clinical indices and biomarkers in risk assessment, and the use of novel anticoagulants, statins, aspirin and beta-blockers in risk mitigation.

Worldwide, non-cardiac surgery is associated with an average overall complication rate of between 7% and 11% and a mortality rate between 0.8% and 1.5%, depending on safety precautions. Up to 42% of these are caused by cardiac complications. When applied to the population in the European Union member states, these figures translate into at least 167,000 cardiac complications annually, of which 19,000 are life-threatening. This highlights the need for guidelines designed to improve peri-operative cardiac risk management in non-cardiac surgery patients. The updated 112 page document with 279 references is freely downloadable from the ESC and EHJ websites(1) and published in the European Heart Journal(2). It will also be available online and in print in the European Journal of Anaesthesiology from September.

The 2014 ESC/ESA Guidelines cover the entire field including surgical risk assessment, pre-operative evaluation, and optimal peri-operative management, and will also address relevant cardiological and anaesthesiological issues in patients with specific cardiac diseases and common co-morbidities who are scheduled to undergo non-cardiac surgery.

These 2014 Guidelines have been released simultaneously with the American College of Cardiology/American Heart Association Guidelines

Indiana University researchers have detected new early-warning signs of the potential loss of sight associated with diabetes. This discovery could have far-reaching implications for the diagnosis and treatment of diabetic retinopathy.

Isis Innovation, the technology transfer arm at the University of Oxford and Canada